Medication Adherence, Health Literacy and Cultural Health Beliefs in a Massachusetts Community Health Center Abstract Health literacy, broadly defined as the wide range of skills and competencies that people use to manage their health (Zarcadoolas, et al. 2005, 196-197), is an important aspect of chronic disease self- management (Mancuso and Rincon 2006), though it has been inconsistently associated with medication adherence in multiple studies. While researchers continue to investigate the relationships among health literacy, medication adherence and health outcomes, few have successfully integrated individual-level factors such as health literacy with structural and social factors. In the proposed research, we rely on ethnographic and qualitative data, in combination with quantitative methods, to explore how medication adherence, a widespread problem in chronic disease management, is shaped by structural factors such as insurance copays, as well as by cultural health beliefs. Building on our previous research (Shaw, et al. 2012a, Shaw, et al. 2009b), the proposed study examines health literacy, health beliefs and barriers to medication adherence among patients from five ethnic groups (African-American, Hispanic, white, Vietnamese and Russian immigrant). We base this study in Massachusetts, which has recently expanded the number of people insured under publicly-funded programs while implementing cost-control measures that may limit access to prescription medications, especially for the poor. Drawing on self-report surveys, pill counts, chart review, in-depth interviews and other qualitative methods, this study will meet the following specific aims: 1. Using two different quantitative methods, to assess medication adherence among patients from 5 ethnic groups: (African-American, Hispanic, white, and Vietnamese and Russian immigrants) with chronic disease (hypertension, diabetes, or dyslipidemia); 2. Use qualitative and ethnographic methods to explore the chronic disease health beliefs that may combine with health literacy to shape medication adherence; 3. To identify factors associated with medication adherence among patients with low health literacy, including: a. beliefs about medicines; b. food insecurity; c. socioeconomic factors (e.g., type of health insurance coverage; formulary changes); and d. social support. 4. To develop recommendations for primary care providers and policymakers to improve medication adherence and mitigate formulary changes among low-income patients with chronic illness. The unique constellation of conditions in Massachusetts-of near-universal insurance coverage coupled with stringent cost control measures as the state struggles to balance its budget-offers an unmatched research opportunity and serves as a critical bellwether for coming changes facing other states with the advent of the Affordable Care Act. The diverse population of patients served by Caring Health Center, the proposed research site, provides a natural laboratory in which to explore the effects of these policy changes as they intersect with culturally variable health beliefs to shape medication adherence among urban, minority and low-income patients. Improved understanding of these complex dynamics will better prepare primary health care providers to improve adherence and help reduce stroke risk among patients with hypertension and other chronic conditions.